Are only Pre-Transplant Rituximab and Plasma Exchange Sufficient for Pre-Transplantation Desensitization Protocol of ABO incompatible LDLT?

Abstract

Backgrounds ABO incompatible living donor liver transplantation (ABOi LDLT) has become a feasible option because of improved outcomes by various desensitization strategies. However, the protocol of ABOi LDLT has not been established worldwide. Nevertheless, the results after transplantation are homogenous. The reports for the results of ABOi LDLT using only rituximab and plasma exchange are scarce. We present the outcomes of our desensitization protocol for ABOi LDLT. Methods From January 2015 to December 2016, we performed 61 LDLTs. Of them, 14 patients received ABOi LDLT. We used only a single dose of rituximab (375 mg/m2) and several plasma exchanges for pre-transplant desensitization in ABOi LDLT and post-transplant immunosuppression consisted of basiliximab, tacrolimus, mycophenolate mofetil and steroid. The target iso-agglutinin IgG titer for transplantation was 1:32. Results The mean initial ranges of iso-agglutinin IgG titers were 124 (range, 4~256). We performed pre-transplant plasma exchange in all recipients (mean number of sessions, 3 (range, 2~5)). The mean peak iso-agglutinin IgG titer after transplantation was 19.5 (range, 0~64). Post-transplant plasma exchange for antibody mediated rejection and rebound elevation of iso-agglutinin titer was not required. One patients received splenectomy with transplantation to prevent small for size graft syndrome. Biliary complications were identified in 5 patients and resolved by biliary stent via percutaneous or endoscopic approach. But, diffuse intra-hepatic biliary stricture was not found in all recipients during short-term follow-up period. The other complications were not identified. Conclusions Both rituximab and plasma exchange along are one of desensitization strategies to eliminate the risk of antibody mediated rejection. And, we believe that complex protocols with splenectomy, intravenous immunoglobulin, and local infusion therapy are not necessary in most ABOi LDLT.